Referral Creation Wizard

Complete the following referral form to submit a request for counselling at Riverside Counselling Service .

How to complete our referral form

You will see 4 tabs: Client, Preferences, Consents and Family Members. To navigate between the tabs, click on next to go forward or previous to go back.

There are twelve mandatory fields which will need to be completed before the system will allow you to progress to the end. They are:

Page 1 - Client

1 Forename

2 Surname

3 Contact Number

4 Address (including postcode)

5 Presenting Issues

This is a drop down box, please click as many options as is appropriate.

6 Why is support required?

This is a text box and your opportunity to let us know why you are looking for counselling now, including any relevant medical/family history. What do you feel might be significant to share with us at this point?

7 When you are available?

This is for your initial consultation. You can discuss your availability for on-going work when you meet with your initial consultation counsellor.

8 GP Details

You must be registered with a GP to proceed. If you cannot see your GP in the pre-selected list, please click on the + icon and add your GP details.

9 Referrer Details

Who told you about Riverside Counselling Service? If the referrer is not listed, you can add a new referrer by clicking on the + icon

10 Household Income

Our fee structure is based on gross household income

Page 2 - Preferences

11. Which location(s) would you like to be seen in?

Page 3 - Consents

12. Consents

In order to proceed with Riverside Counselling Service we require you to check our GP consent box. This gives us your consent to share details with your GP and other parties involved in your care. Without this we cannot proceed with your enquiry.

Page 4 – Family Members

If you are under 18 or a parent or referrer completing on behalf of an under 18 year old, you will be asked to provide Parent/Guardian Name and Contact Number and can add your details to the Family Members tab. If you have other close family members within the service, such as a partner, this is also useful for us to know and the details can be added to the Previous Service field .

Email, date of birth, gender, or school (for under 18) are optional, but helpful for us to know.

 

 

Client

Defaults to today’s date
Select title
Enter preferred name if applicable
Enter forename
Enter surname
Enter contact number
Enter house number and street
Enter town/city
Select country
Select county
Enter full postcode (e.g BT3 9DT or SW1A 1AA)
Enter an email address.
Enter date of birth
Select gender.
Select pronoun.
If under 16 enter name and contact number
Enter name of school
Select referral source (e.g Friend, GP, School, Self Referral etc)
Select person / organisation making the referral OR click '+' icon to add a new Referrer

 

Please select all presenting issues that apply
Please select a how did you hear about us option
Please enter the other source
Search and select your GP. Use the '+' icon below to add your gp if not found

 

Please provide brief details of why support is required.
Please tick box if you have previously had counselling
Please could you give us the name of anyone who is known to you, who currently uses the counselling service or may have used the counselling service in the last two years. We ask this question to ensure that we allocate you to a different counsellor.
Please provide details of days/time you are available
Please provide details of any medication, including dosage.
Please provide any additional information you feel relevant including any involvement with other mental health services
Enter gross household income

Preferences

Please select any special requirements you might need (Select all applicable).
Please select a location
Are ground floor facilities required?
If they are, please provide some detail regarding this.

Family Members / Contacts

Contact Information

Tick if this contact may attend appointments.
Select title.
Enter forename.
Enter surname.
Enter preferred name if applicable.
Enter email address.
Enter date of birth.
Select the contacts relationship.
Select gender.
Enter contact number.
Please enter a contact number

Address Information

Tick if you would like to copy the address from the primary client.
Enter a street and house number.
Please enter a street
Optionally enter a town.
Please enter a town
Select a country
Please select a country
Select a county
Please select a county
Enter full postcode (e.g BT3 9DT or SW1A 1AA)
Please enter a valid postcode
Clear
  • No records assigned.

Consents

How we use client information

In order to provide an effective and professional counselling service, Riverside holds information about you, which includes contact details, information about your GP, date of birth, source of referral, previous experience of counselling and medication used and a brief session note. Your personal data will not be shared with anyone outside Riverside without your knowledge and permission, unless any of the following apply:

1 When a counsellor has good grounds for believing that a person may cause serious harm to themselves or others.

2 When we are instructed by a court to disclose information.

3. When a person discloses serious criminal activity, or knowledge of serious criminal activity, this includes statutory obligations in relation to terrorist activity and is a legal requirement.

4 When it is necessary to uphold child protection laws.

Your personal data is usually held by Riverside for 7 years after you have finished counselling.

Riverside is accredited by the British Association for Counselling and Psychotherapy (BACP) and all our counsellors comply with the BACP’s Ethical Framework for the Counselling Professions. In accordance with their professional requirements, counsellors discuss their work with an external supervisor, but the identity of the client is not revealed. Case material may sometimes be used anonymously by counsellors to enhance their practice and professional development. Anonymised data is used for the purposes of accounting, fundraising, preparing annual reports, publicising Riverside’s work, raising awareness and research. You can ask to see the information held about you at any time and a data subject access request will be responded to within 30 days of your request.



Your responsibility

We would ask that you keep us informed (by email, telephone, or in writing) of any changes in your personal data so that we may have our records up to date at all times. If you wish to withdraw your consent please contact us (by email, telephone, or in writing). You have the ‘right to be forgotten’, which means you can request the deletion or removal of personal data where there is no compelling reason for its continued processing.


GP/3rd Party Consents

I consent to having my information held as outlined above and confirm that I have given Riverside permission to refer, in respect of my counselling, to my GP or any other health professional involved in my care.

Why does Riverside need this? In some exceptional circumstances, for example if there is an immediate concern about your physical or mental health, we may need to contact your GP for your safety. We would always try to discuss this with you
first. We do not disclose the exact content of your counselling sessions to your doctor. Please note that we cannot proceed with your referral unless we receive your consent, if you have any questions about this, please call: 01491 876670.

Communication Consents

Tick your preferred methods of consent from the list below. Please TICK ALL that apply (a minimum of one must be selected)

I consent that I'd like to hear from you via email

I consent that I'd like to receive phone calls from you and you can leave voice messages

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you